Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Additional Documentation and Certification Modified 30 23 0 Form 3 Certification Form
Form 1 Certification Form - Clean
Form 1 Certification Form - Redline
Authorization for Use or Disclosure of Health Information Form Modified 100 200 0 Form and Instruction 2 CICP Authorization Form
Form 1 CICP Authorization Form in Spanish - Redline
Form and Instruction 1 CICP Authorization Form Instructions in Spanish - Redline
Benefits Package and Supporting Documentation Modified 30 4 0 Instruction
Instruction
Instruction
Form 4.1 Certification of Status for Death Benefit – Alternate Calculation
Form 4.2 Certification of Status for Death Benefit - Standard Calculation
Form 4.3 Certification of Survivor Relationship to Deceased Injured Countermeasure Recipient
Form 4.4 Certification of Status for Administrators of the Estate: Lost Employment Income
Form 4.5 Certification of Status: Lost Employment Income
Form 4.6 Certification of Status: Unreimbursed Medical Expenses
Instruction
Instruction
Instruction
Form and Instruction Attachment 2 Unreimbursed Medical Expenses Certification A (Clean)
Form and Instruction Attachment 2 Unreimbursed Medical Expenses Certification (Redline)
Form and Instruction Attachment 3 Lost Employment Income Certification A (Clean)
Form and Instruction Attachment 3 Lost Income Certification A (Redline)
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Form and Instruction Attachment 2 - Estate Unreimbrused Medical Expenses Certification (Clean)
Form and Instruction Attachment 2 - Estate Unreimbursed Medical Expenses Certification (redline)
Form and Instruction Attachment 3 - Estate Lost Income Certification
Form and Instruction Attachment 1 - Survivor Certifcation of Status for Death Benefit (clean)
Form and Instruction Attachment 1 - Survivor Certification of Status for Death Benefit - Redline
Form and Instruction Attachment 2 - Survivor Certification of Status for Death Benefit - Alternative Calculation (Clean)
Form and Instruction Attachment 2 - Survivor Certification of Status for Death Benefit - Alternative Calculation (redline)
Form and Instruction Attachment 3 - Survivor Survivor Attachment 3 - Death Benefit Certification of Relationship Redline
Countermeasures Injury Compensation Program Request Package Modified 100 1100 0 Form 1 CICP Request Form
Form and Instruction 1A CICP Request Form Instructions
Form and Instruction 1 CICP Request Form (with Color) in Spanish - Redline
Form and Instruction 1 CICP Request Form Instructions in Spanish - Redline
Total burden requested under this ICR: 260 1327 0  
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